Provider Demographics
NPI:1588952303
Name:DECI, EDWARD L (PHD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:L
Last Name:DECI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14610-1619
Mailing Address - Country:US
Mailing Address - Phone:585-442-7284
Mailing Address - Fax:
Practice Address - Street 1:429 MELIORA HALL
Practice Address - Street 2:UNIVERSITY OF ROCHESTER
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14627-0266
Practice Address - Country:US
Practice Address - Phone:585-275-2461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-13
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4958-1103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP37281Medicare PIN